Case Management Plan of Care

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					                    Southwest/Piedmont HIV Care Consortium
                               Ryan White Part B
            Comprehensive Case Management Individualized Service Plan

Service planning is the process of detailing client’s goals and needs and developing an action
plan to achieve these goals or meet the needs while assisting the client to achieve a positive
medical outcome. The case manager (CM) and client (or client representative) jointly develop the
NRHD Ryan White Part B Comprehensive Individualized Service Plan (ISP) within the first 45
days of enrollment.

Client’s Statement and Agreement – CM reviews with client. Client indicates whether he/she
accepts or declines to receive a copy of the completed service plan and initials.

Utilizing the NRHD Level of Care Assessment and any other information discussed in the
client/CM interview process, the parties identify each problem to be addressed, relate the
problem(s) to the Outcome Measurement Scale (OMS) located on back of ISP, and complete the

Date Initiated:           Enter the date the CM and client agree to work on the particular
Problem:                  Enter the specific issue indicated on the Outcome Measure Scale
                          (OMS) located on back of ISP
Goal:                     Record the desired outcome should problem be resolves; also relates
                          to OMS
OM/Initial Score:         Enter the specific area on OMS being addressed and outcome score
                          based on level of intervention necessary
Initials:                 Both client and CM must initial in acknowledgement of participation in
                          resolving problem
Actions/Target Date:      Record specific steps to be taken included anticipated date of action
Responsible Party:        Enter individual responsible for completing step(s)
Result:                   Record what was achieved by the completion of the action step(s)
Reassessment Score:       Upon completion of action steps, client (OMS) score should be
                          reevaluated and recorded to determine measure of progress made
Reassessment Date:        Enter date of reevaluation of score

Date Resolved should be recorded only after the problem is no longer to be addressed, meaning
either of the following conditions are met:
        Problem is no longer identified as a barrier to an immediate need.
        Change in score indicates a new approach to problem. In this case, the CM needs to
            complete the appropriate steps as listed above.

The ISP may be reviewed/revised as necessary but at least every 90 days.


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